The Mind Matters

Some years ago, a study by Gill and associates1 regarding the use of alternative medicine among diabetic patients in the United Kingdom led the authors to conclude that
there is cause for concern: insulin-dependent patients were found to have reduced or even stopped taking their insulin in
favor of therapeutic approaches including prayer, faith healing, unusual diets, and supplements of vitamins and trace elements.
The authors could understand that diabetic patients could experience their treatment as “somewhat unsatisfactory” and therefore
seek alternative treatments making more attractive claims.

A survey conducted in the United States by Astin,2 however, has shown that dissatisfaction with conventional medicine is not the main motive for using alternative medicine.
Rather, most alternative-medicine users appear to be doing so because they find these health care alternatives to be more
congruent with their own values, beliefs, and philosophical orientations toward health and life.

Interestingly, many of the therapies commonly labeled as “alternative” in fact are psychological techniques, e.g., relaxation
and hypnosis, and apparently there is a growing market for professionals in the field of “mind-body interventions.”3 As a psychologist trained in health psychology and behavioral medicine, I question whether applications of such psychological
techniques should be regarded as alternative medicine. Complementary, perhaps? To illustrate my point, I offer a short historical overview:

In the early days of medicine, patients were treated with a variety of what we would now consider bizarre and largely ineffective
therapies. Egyptians, for example, were medicated with lizard blood, crocodile lung, the teeth of swine, and fly specks. If
patients did not succumb of their disease, they had a good chance of dying from its treatment.

It is important to note that in those days, mind and body were considered a unit. Disease was believed to arise when evil
spirits entered the body, and these spirits could be exorcised through the treatment process.

The Greeks were among the first to hypothesize a mind-body split. Rather than ascribing illness to evil spirits, Hippocrates,
considered by many “the father of medicine,” developed a humoral theory of illness. Disease was thought to arise when the
four circulating fluids, or humors, of the body—blood, black bile, yellow bile, and phlegm—were out of balance. The function
of treatment was to restore the balance among the humors.

In the Middle Ages, mysticism and demonology dominated conceptions of disease. Cure often consisted of driving out evil by
torturing the body. Later, this was replaced by penance through prayer and good works. Medical practices included religiously
based but unscientific generalizations about the mind-body relationship; healing and the practice of religion became indistinguishable.

During the Renaissance, first attempts were made to break with the superstitions of the past. In the seventeenth century,
a dualistic conception of mind and body was further reinforced by scientific discoveries and publications from Descartes and
others reflecting a strong belief in a mechanistic understanding of the human body. Physicians became the guardians of the
body, while philosophers and theologians became the caretakers of the mind. For the next three centuries, physicians focused
primarily on organic and cellular changes and pathology as a basis for their medical interventions and with great success,
as we know.

The reductionist, biomedical model is still the dominant model today, but we have seen a growing appreciation of psychological
factors in the past decades.4 We have come to learn that the mind and the body cannot be meaningfully set apart in matters of health and illness. In diabetes,
this is simply illustrated by the fact that psychological stress can seriously disrupt blood glucose control, both directly
through stress hormones and indirectly via changes in self-care behaviors. Conversely, extreme high and low blood glucose
levels can profoundly change a patient’s mood state and subsequently affect self-care behavior and social interactions. Mind
and body are inextricably interwoven. Many patients have already made that discovery, although it is not always fully appreciated
by their physicians.

Effective diabetes treatments are available, but they are certainly burdensome and by no means perfect. I can sympathize with
those who are worried about patients using dubious, expensive, and potentially harmful “alternative” treatments. However,
in the case of body-mind interventions for diabetes, there is no need to worry, as long as practitioners make no unrealistic
claims. Techniques such as relaxation and hypnosis have been shown to be beneficial in cancer and chronic pain. Positive effects
have also been reported, although not consistently, in diabetes.

Some may suggest that we are looking at placebo effects. Maybe, but the placebo effect is not necessarily “just psychological,”
as stereotypes would have us believe. The placebo response can be a complex, psychologically mediated chain of events that
often has physiological effects. For example, a placebo may reduce anxiety and hence reduce levels of epinephrine, thereby
improving a person’s sense of mastery, emotional well-being, self-esteem, and social functioning, as well as his or her metabolic
control. There is also evidence that the effectiveness of a placebo varies depending on how practitioners interact with patients
and how much practitioners believe in the curative powers of the treatment being offered. Studies have shown that simply taking
time with patients and not rushing them strengthens the effects of a placebo. Apparently, even effective drugs seem to lose
much of their impact when practitioners express doubt about their effectiveness.

Clearly, the mind matters in diabetes. Man is not simply a machine, as Descartes suggested more than 300 years ago. It seems
we have come full circle in our beliefs about the mind-body relationship. Body and mind clearly interact and in complex ways
that we do not yet fully understand. To me, taking the mind into consideration is anything but “alternative”and is certainly
congruent with a holistic approach to caring for people with diabetes.

Footnotes

Frank J. Snoek, PhD, is an associate professor of medical psychology in the Department of Medical Psychology, Diabetes Research
Group, at the Vrije Universiteit Medical Centre in Amsterdam, the Netherlands, and an associate editor of Diabetes Spectrum.